Motivational Interviewing Skills & Client Responses Analysis

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J Subst Abuse Treat. Author manuscript; available in PMC 2018 November 22.
Published in final edited form as:
J Subst Abuse Treat. 2018 September ; 92: 27–34. doi:10.1016/j.jsat.2018.06.006.
A sequential analysis of motivational interviewing technical
skills and client responses
M. Barton Lawsa,*, Molly Magillb, Nadine R. Mastroleoc, Kristi E. Gamareld, Chanelle J.
Howee, Justin Walthersb, Peter M. Montib, Timothy Souzab, Ira B. Wilsona, Gary S. Rosef,
and Christopher W. Kahlerb
aDepartment of Health Services, Policy and Practice, Brown University School of Public Health,
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Providence, RI, United States
bDepartment of Behavioral and Social Sciences and the Center for Alcohol and Addiction Studies,
Brown University School of Public Health, Providence, RI, United States
cCollege of Community and Public Affairs, Binghamton University, Binghamton, NY, United States
dDepartment of Health Behavior and Health Education, University of Michigan School of Public
Health, Ann Arbor, MI, United States
eDepartment of Epidemiology, Centers for Epidemiology and Environmental Health, Brown
University School of Public Health, Providence, RI, United States
fWilliam James College, Newton, MA, United States
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Abstract
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Background: The technical hypothesis of Motivational Interviewing (MI) proposes that: (a)
client talk favoring behavior change, or Change Talk (CT) is associated with better behavior
change outcomes, whereas client talk against change, or Sustain Talk (ST) is associated with less
favorable outcomes, and (b) specific therapist verbal behaviors influence whether client CT or ST
occurs. MI consistent (MICO) therapist behaviors are hypothesized to be positively associated
with more client CT and MI inconsistent (MIIN) behaviors with more ST. Previous studies
typically examine session-level frequency counts or immediate lag sequential associations between
these variables. However, research has found that the strongest determinant of CT or ST is the
client's previous CT or ST statement. Therefore, the objective of this paper was to examine the
association between therapist MI skills and subsequent client talk, while accounting for prior
client talk.
Methods: We analyzed data from a manualized MI intervention targeting both alcohol misuse
and sexual risk behavior in 132 adults seen in two hospital emergency departments. Transcripts of
encounters were coded using the Motivational Interviewing Skills Code (MISC 2.5) and an
additional measure, the Generalized Behavioral Intervention Analysis System (GBIAS). Using
*
Corresponding author at: Department of Health Services, Policy and Practice, Brown University School of Public Health, G-S121-7,
Providence RI 02912, United States. [email protected] (M.B. Laws).
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jsat.2018.06.006.
Laws et al.
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these measures, we analyzed the association between client talk following specific classifications
of MICO skills, with the client's prior statement as a potential confounder or effect modifier.
Results: With closed questions as the reference category, therapist simple reflections and
paraphrasing reflections were associated with significantly greater odds of maintaining client talk
as CT or ST. Open questions and complex reflections were associated with significantly greater
odds of CT following ST, were not associated significantly with more ST following ST, and were
associated with more ST following CT (i.e., through an association with less Follow Neutral).
Conclusions: Simple and paraphrasing reflections appear to maintain client CT but are not
associated with transitioning client ST to CT. By contrast, complex reflections and open questions
appeared to be more strongly associated with clients moving from ST to CT than other techniques.
These results suggest that counselors may differentially employ certain MICO technical skills to
elicit continued CT and move participants toward ST within the MI dialogue.
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Keywords
Change talk; Motivational interviewing; Sequential analysis; MI technical skills; Sustain talk
1.
Introduction
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Motivational Interviewing (MI) is among the most widely-used approaches to effect
behavior change. It was originally developed in the 1980s to address alcohol misuse (Miller
& Rollnick, 2012). It has since been extended to other behavioral domains, and metaanalyses have found it to be effective for many targeted behavioral changes such as physical
activity and medication taking (Lundahl & Burke, 2009). However, effect sizes are highly
variable, and not all trials show effectiveness (Ball et al., 2007; Hettema, Steele, & Miller,
2005; Miller, Yahne, & Tonigan, 2003; Winhusen et al., 2008). This has spurred interest in
gaining a better understanding of the mechanisms of behavior change in MI to optimize its
effectiveness.
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A central hypothesized mechanism in MI is client motivational language. Specifically, the
technical hypothesis proposes that “change talk” (CT) — client speech during the session
that indicates motivation, preparation, and commitment to behavior change — is associated
with better behavioral outcomes, whereas talk against change —counterchange, resistance,
or “sustain talk” (ST) — is associated with less behavior change. There is growing evidence
supporting the relationship between client CT and behavioral outcomes (Apodaca &
Longabaugh, 2009; Miller & Rose, 2009; Moyers et al., 2007). Yet, some studies find more
specific or limited relationships, suggesting these may be complex associations requiring
increasingly nuanced methodologies. At an aggregate level, meta-analyses show more ST is
associated with less behavior change, a combined measure of CT and ST is associated with
more behavior change, and CT alone does not have a predictive effect (Magill et al., 2014).
Another recent meta-analysis similarly found that ST was associated with worse MI
outcomes, and the effect for CT was non-significant (Pace et al., 2017).
Perhaps the most distinctive contribution of the MI theoretical literature is the technical
component, which underscores the importance of identifying, eliciting, and reinforcing
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client CT. An early principle in the development of MI was that arguing against resistance,
or confrontation, is counterproductive as it tends to elicit more resistance, in part because it
limits patients' perceived autonomy (Moyers, Miller, & Hendrickson, 2005). Practitioners
highly skilled in delivering MI successfully elicit CT, identify various types of CT, and
reinforce CT through the use of skillful reflective listening, while also “rolling” with client
resistance.(Miller & Rollnick, 1991).
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Several studies have evaluated processes occurring in MI sessions to determine whether the
technical component of MI operates as hypothesized. Evaluations of MI processes typically
utilize the Motivational Interviewing Skill Code (MISC) (Miller, Moyers, Ernst, & Amrhein,
2003), and subsequent versions and extensions of the system. In the MISC, specific
counselor verbal behaviors are encoded and can be classified as MI consistent (MICO) and
MI Inconsistent (MIIN). Subsequently, the relationship between MICO and MIIN categories
and client CT and ST can be examined, typically in correlations of session-level frequency
measures or in sequential analyses. Sequential models, which preserve the temporal
sequence between counselor behaviors and client responses, may provide a more specific
estimate of how therapists elicit motivational statements within clients. In fact, although
effect sizes for the correlation between MI skills and client change statements are
“moderate”, they are “small” when temporal precedence is taken into account (Magill et al.,
2014).
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Sequential analyses of how MI skills are associated with subsequent client language have
numerous conceptual and methodological strengths allowing for a more direct examination
of the technical hypothesis than cross-sectional analyses. However, there are also some
limitations and challenges with such investigations. Conceptually, a sequential model derives
probabilities that certain types of statements will follow certain types of statements from the
other speaker in a predictable manner. The method was popularized in the marital therapy
literature by John Gottman and colleagues in the 1980s. In the MI literature, a body of
sequential research emerged via the development of the Sequential Code for Observational
Process Exchanges (MI-SCOPE) (Martin, Moyers, Houck, Paulette, & Miller, 2005). In
these studies, the types of client statements of interest are typically summary measures such
as CT, ST, and utterances which are neither (i.e., Follow Neutral [FN]). Therapist utterances
could be classified as MICO or MIIN, or more specifically, if frequency of occurrence
allows. In sequential analysis, these labels can be called “states” and the relationship
between an utterance and the following utterance is termed a “transition.” These therapist
behaviors can be called “elicitations.”
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Sequential analyses have the capacity to extend our understanding of the association
between counselor technique and client response. For example, an analysis of data from a
smoking cessation intervention in Sweden (Lindqvist, Forsberg, Enebrink, Andersson, &
Rosendahl, 2017) found that clients were more likely to produce CT following MICO
behaviors and questions and reflections favoring change, and were more likely to produce
ST following reflections of ST. This study also found that MIIN utterances were not more
likely than chance to be followed by ST, but rather by FN. They speculate that this may be
because ST did not occur at lag one, but did occur later.
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Another study that computed all transition probabilities using categories from the MISCOPE found that reflections of change talk were more likely to be followed by change talk
than by chance, and that reflections of counterchange talk were also more likely to be
followed by counterchange talk (Moyers, Martin, Houck, Christopher, & Tonigan, 2009).
These authors conclude that “To obtain better outcomes using MI, clinicians should attend
carefully to client language about change and use strategies recommended in the practice of
MI (asking questions likely to result in change talk, reflecting change talk when it occurs,
and emphasizing client choice) to gain more of it. (p. 1121).
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A study of MI for alcohol treatment found that reflections of CT were likely to be followed
by CT, and that the probability of CT followed by CT in the next client utterance was
associated with reduced drinking (Houck & Moyers, 2015). Two studies that examined all
transition types (e.g., therapist to client, client to client, client to therapist), found that in
client-to-client transitions the previous client state was more strongly associated with the
subsequent client state than was any intervening therapist elicitation (Gaume, Bertholet,
Faouzi, Gmel, & Daeppen, 2010; Romano, Arambasic, & Peters, 2017). A study of a group
MI intervention for adolescents found that open questions and reflections of change talk
were more likely than change to be followed by change talk, that reflections of sustain talk
tended to suppress subsequent change talk, and that change talk by group members was
more likely than chance to be followed by more change talk. This situation is not directly
comparable to individual counseling since the previous “client state” may not have been
produced by the same person who makes the next client utterance, but does reinforce that it
may be important to distinguish among MI consistent therapist behaviors and to account for
the context in which they appear (D'Amico et al., 2015).
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This work suggests we are making progress in understanding the MI technical component
via sequential modeling and when the odds of specific client responses are of interest, it is
important to take into account the prior client state.
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Sequential analyses at more than one lag can be computationally intractable because the
number of transitions increases exponentially with additional lags. For this reason,
sequential analyses typically examine only the transition between one utterance and the one
immediately following. However, the first MISC-coded statement within a longer series of
utterances will not necessarily capture the crux of the client's verbal intent. We argue the
sequential model should account for all client statements between a given therapist
elicitation (i.e., question or reflection) and the next. Moreover, the last client CT or ST
utterance in the sequence may best represent the overall direction of the response toward or
away from behavior change. Consider the following example from the data used in the
present study. (I = Interventionist, P = Participant):
I: So tell me about that experience, what it's like the next day.
P: You don't wanna be like that. But, I mean, that's when I start regretting it and
then, uh, you know, we [referring to her friends] talk about it and I say, you know, I
probably wouldn't have done that if we not were drinkin', but doesn't bother us
enough to stop (laughter).
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The initial utterance following the counselor's elicitation (in this case an open question)
would be coded as CT. However, the participant's final utterance is ST indicating that she is
not ready to change in spite of negative consequences.
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The purpose of the present study is to build upon the prior sequential model literature by
examining the relationship between therapist elicitation interventions and subsequent client
motivational statements – CT, ST, or FN while taking into account clients' prior state. We
use an expanded model that incorporates all client utterances following an elicitation
“episode” up to a defined therapist behavior that terminates that episode (please see Methods
for further description). We incorporate the client's previous state (i.e., whether the prior
episode is labeled as ST, CT, or FN) as an effect modifier, with the hypothesis that the odds
of elicitations resulting in subsequent client language will depend upon the client's prior
state. Finally, because MI therapist elicitation interventions are of primary interest, we
extend the commonly used classification grouping for therapist skills to include a more
comprehensive typology identified within the MI-SCOPE (Martin et al., 2005). We expected
that some techniques would be more likely than others to be associated with transitions from
ST to CT, while others might be associated with maintaining the prior state. The goal of this
work is to provide MI therapists with specific guidance on how MI techniques can function
in eliciting a range of client motivational responses.
2.
Material and methods
2.1.
Parent trial description
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This study is based on analysis of data from a randomized controlled trial of a brief (one
session) MI intervention, compared to a brief advice control (Monti et al., 2016). Patients
were not treatment seeking, but were recruited during visits to two Emergency Departments
(EDs). The intervention targeted both risky alcohol use and sexual behavior. Patients age
18–65 were screened using the Alcohol Use Disorder Identification Test (AUDIT)
(Saunders, Aasland, Babor, De la Fuente, & Grant, 1993), and completed a questionnaire on
drinking and sexual risk behavior. Eligible subjects scored ≥8 on the AUDIT (males) or ≥6
(females), or endorsed at least one episode of binge drinking in the past 30 days (≥ 5 drinks
for males, ≥ 4 drinks for females); and reported engaging in at least one sex risk behavior in
the past 3 months. Behaviors included having condomless sex with a non-steady partner,
condomless sex with a steady partner where infidelity was suspected, and having sex under
the influence of alcohol or other drugs.
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Patients completed the screening, enrollment, and baseline assessment while at the ED, and
were then randomized. They completed the MI session in the ED within 2 weeks of the
baseline assessment. One hundred eighty four study participants were randomized to the MI
condition, of whom 169 completed the session. The sessions were audio-recorded and later
transcribed for coding and analysis. Of the 169 transcripts, 132 were randomly selected to be
coded for this study due to resource limitations.
The manualized MI session consisted of components including open-ended exploration of
the pros and cons of drinking and risky sexual behavior, feedback and normative
comparisons drawn from responses to baseline assessments, and change planning for clients
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who were interested. The structure of the intervention was such that the therapists were
instructed to intentionally elicit both CT and ST in the early part of the session (i.e.,
ambivalence exploration), before transitioning to a focus on solidifying motivation in the
direction of change (i.e., reduced alcohol use and sex risk behaviors). The change plan,
when it occurred, also typically required that therapists engage in some intentional
elicitation of ST in order to identify possible barriers to change and develop solutions.
Sessions were typically 60 min in length, and participants were compensated with $50.
Therapists received 20 h of training, including didactic presentations and simulated roleplays, and received ongoing group supervision with review of audio recordings of sessions.
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The intervention, compared with brief advice and controlling for baseline covariates, was
associated with fewer heavy drinking days, fewer drinks per week, and overall reduced
likelihood to engage in excessive drinking over 6 and 9 month follow-ups. It was also
associated with lower odds of reporting condomless sex with a casual partner, and fewer
days of sex under the influence of alcohol and/or other drugs (Monti et al., 2016).
2.2.
Process measurement, procedure, and process variables of interest
As detailed in the MISC, therapist behaviors can be classified as MI-consistent (MICO) or
Mi-inconsistent (MIIN). MICO behaviors include Affirm, Advise with Permission,
Emphasize Control, Raise Concern with Permission, Support, Open Questions, and
Reflections (simple or complex). MIIN Behaviors are Advise without Permission, Confront,
Direct, Raise Concern without Permission, and Warn. Additional, or “Other” practitioner
behaviors include Closed Questions, Giving Information, Structure, and Facilitate.
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For the present study, we developed additional therapist skill codes to extend and enhance
the information provided by the MISC 2.5 (Houck, Moyers, Miller, Glynn, & Hallgren,
2010), some of which is analyzed and described elsewhere within the Generalized
Behavioral Intervention Analysis System (GBIAS) (Kahler et al., 2016). Coding manuals are
available at https://doi.org/10.7301/Z0Z60MKW. The speech act component of the GBIAS
is based on the Generalized Medical Interaction Analysis System, which is described in
detail elsewhere (Laws et al., 2013; Laws et al., 2014). The GBIAS assigns specific codes to
what would otherwise be undifferentiated therapist and client utterances within the MISC,
and includes categories for speech acts such as representations of facts, deductions or
conclusions, self-reports of behavior, or expressions of affect. The additional content of
relevance to this report includes an expanded typology of therapist elicitation behaviors,
which are described in detail in Table 1.
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In the GBIAS, simple reflections, as in MI systems, are defined as restatements of client
speech with no change in meaning – often literal echoing. By contrast, paraphrasing
reflections repeat content of client speech with some small extension of meaning. Examples
of these are given in the MISC manual but they are not given an explicit label, but rather
conflated with complex reflections generally. An example would be:
Client (C): Like, I just, I'm such a paranoid person, it's [drinking] helpful.
Therapist (T): So for you, you know, you have that little bit of anxiety around
people, and alcohol is a way to kind of help lessen that anxiety for you.
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Or:
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C: Drinking makes it so much easier for me to talk to new people.
T: You're more social and less nervous around new people when you drink.
(These are the role designations given in the MISC manual, not the ones we use
here.)
The theoretical intent is to test the therapist's interpretation of the client's statement without
the directiveness of a closed or leading question. However, if these therapist utterances are
said with a rising (questioning) inflection, they are not coded as reflections but as leading
questions, which are treated as closed questions in this analysis.
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More elaborate forms of complex reflection are classified in the GBIAS similarly to the
MISC manual. As these forms of complex reflection were individually fairly uncommon, we
combined them for analysis. (See Table 1.) In the MISC, however, they are conflated with
what we call paraphrasing reflections, and with summarizing reflections.
In a summarizing reflection, the therapist pulls together highlights of a complex story told
by the client, perhaps over several preceding turns, in a succinct restatement. This usually
brings a topic to a close and signals a new direction for the dialogue, rather than necessarily
being intended as an elicitation. Since it typically includes reflections of both CT and ST,
client agreement cannot necessarily be given a valence as either CT or ST.
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Consistent with the MISC, we consider a facilitative utterance as a brief, often non-lexical
utterance such as “uh-huh,” which merely signals that the speaker is listening and continues
to cede the floor to the speaker. Words such as “yeah” and “okay” often have this function
and do not necessarily signal agreement. Simple reflections have essentially the same
function but are encouraged as they are assumed to provide a stronger signal of active
listening. Finally, the GBIAS labels the therapist speech act “ask for permission,” and
various forms of advice or instruction (e.g. directing, suggesting, disapproval of a behavior),
allowing the MICO behavior “advise with permission” to be constructed from a sequence of
speech acts.
For purposes of this study, we used the MISC coding of participant utterances as CT, ST, or
FN, and did not distinguish further. Only 1.6% of MISC-coded therapist behaviors were
MIIN (range 0–7.3 per session). The purpose of this study was to examine the relationship
between various therapist elicitations – the MI consistent behaviors – and transitioning
between previous participant CT, ST, and FN, and subsequent client talk.
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2.3.
Coder training
A total of 7 coders participated over the course of the study. They held master's degrees in
psychology, linguistics, or relevant fields. Coders received about 60 h of training on both the
GBIAS and MISC systems. Training involved an initial didactic session, individual and
group practice with corrective feedback, and coding of the same material by multiple coders
followed by discussion and resolution of discrepancies. This process also served to refine the
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coding manuals. Some coders exclusively did MISC coding, and some did both GBIAS and
MISC. Coders listened to the audio of the encounters while coding transcripts.
2.4.
Coding reliability
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Inter-rater reliability was assessed continuously throughout data collection. After coding
every fifth session, a segment of at least 300 utterances was randomly chosen from
completed interviews and assigned to a randomly selected second coder. Reliability and
agreement statistics were computed and disagreements discussed in bi-weekly meetings.
Nineteen encounters were randomly selected for doublecoding. For the MISC double coding
of utterance-level data, the mean kappa statistic was 0.79, which indicates substantial
agreement (Cohen, 1960). Additionally, the majority (79.6%) of item-level Intraclass Class
Correlation values for the codes used in this study were in the “good” to “excellent” range
(Chicchetti, 1994). Results for GBIAS speech acts were similarly good, with reliability at
the integer level k = 0.82, and k = 0.70 for the second digit, the lowest level used in this
analysis.
2.5.
Definition and classification of “episodes”
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We defined an “episode” as all client statements beginning after a therapist elicitation and
ending with the client utterance immediately preceding either the next therapist elicitation,
or other therapist behaviors that terminate the client's train of association, including factual
representations, therapist expression of his or her own opinions, and overt topic closures or
changes; or client topic changes or questions. We classified elicitations as closed questions
(the reference category in analyses), open questions, paraphrasing reflections, other complex
reflections listed in Table 1, and summarizing reflections, along with advice with
permission. We ignored facilitative utterances and simple reflections on the assumption that
these do not function as elicitations per se but merely encourage the client to continue on his
or her own course. (We tested this assumption in the analysis as described below.)
We called client episodes consisting of more than one MISC-coded utterance “multiple
episodes.” When these utterances consisted entirely of CT, ST, or FN, they were labeled
accordingly. Episodes including both CT and ST were classified according to the last CT or
ST statement in the episode, based on the presumption that the episode's terminal utterance
is the best indicator of its overall thrust of meaning, and also provides the baseline state for
the subsequent episode. To make this determination we examined a randomly chosen sample
of 20 mixed episodes and found this presumption to be most consistent with the observed
data.
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Simple reflections are often included with other MICO behaviors in a summary measure,
and their association with CT and ST is tested. However, we believed that simple reflections
function similarly to facilitative utterances and simply tend to maintain a given line of
participant speech. As shown in Table 2, analysis of episodes in which facilitative utterance
and simple reflections were considered as therapist elicitations were consistent with this
supposition. Following either type of therapist behavior, the next segment of participants'
speech was most likely to be coded consistent with the prior segment. In fact, simple
reflections were even more likely to maintain client ST and CT than were facilitative
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utterances. For a statistical test of this observation, we cross tabulated simple reflection and
facilitative utterances with the outcome that ST, CT or FN was maintained in the subsequent
client utterance. Simple reflections were associated with maintaining the client's previous
state 56.8% of the time, compared with 43% for facilitative utterances. (P < .0001
accounting for clustering within clients.) Accordingly, we felt it appropriate not to treat these
as elicitations, and to use our episode definition as originally conceived. Therefore episodes
may include facilitative utterances and/or simple reflections but these elicitation types are
ignored in all subsequently described multivariable analyses.
2.6.
Multivariable analyses
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We used Generalized Estimating Equations (GEE) logistic regression models (Liang &
Zeger, 1986) to estimate Adjusted Odds Ratios (AORs) for producing CT and ST episodes,
respectively, as a function of the various therapist elicitation types (reference = closed
question) and selected covariates. The outcome was a repeated binary indicator of CT or ST
being produced after an elicitation. Model covariates included prior CT and FN (reference =
ST), the early component of the intervention in which ST is intentionally solicited vs. later
components, as well as client age, race/ethnicity (dichotomized as white, non-Hispanic vs.
all other racial/ethnic groups due to sample characteristics), gender, level of formal
education (high school only or more than high school), study site, and therapist. All
predictors were included in the GEE models as indicator variables with the exception of
client age which was included as a linear term. After fitting the above described main effects
models, we added product terms between the prior states and the elicitations to observe
whether the relationship between elicitations and subsequent CT and ST episodes was effect
modified by prior states. Because there were 15 product terms in these full models and some
of them were statistically significant, we chose to simplify interpretation of the findings by
fitting main effects models restricted to the sample of episodes that included prior CT, prior
ST, or prior FN, respectively, to estimate the AORs for subsequent CT and ST as a function
of elicitation type. All GEE models accounted for clustering within participant while
specifying an exchangeable working correlation matrix.
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3.
Results
3.1.
Descriptive data
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Of the 132 subjects, 74 (56.1%) were female. Subjects ranged in age from 18 to 60, with a
median age of 26. One hundred thirteen (86%) reported White race, 17 Black and 9 Native
American including a few reporting multiple race. Forty percent reported having a high
school diploma or GED, and 44% at least some college. Forty-one percent were
unemployed, and one-third had incomes of less than $10,000/year. Three reported being
homosexual, 13 bisexual, and 1 not sure.
For the 132 subjects, there were a total of 3450 intervals containing participant CT or ST
that did not follow a therapist elicitation (mean 26.1 per encounter). Some of these provided
the baseline state for a transition following an elicitation, but we do not otherwise consider
them here. There were a total of 17,355 episodes following a therapist elicitation (mean
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131). Of these, 9961 (57.4%) consisted of a single MISC-coded client utterance, of which
4302 (43.2%) were CT; 1270 (12.7%) were ST; and 4389 (44.1%) were FN.
Of the 7394 (42.6%) episodes containing > 1 MISC-coded utterance, counting only CT and
ST, and excluding FN, 2354 consisted of 2 utterances, and 1198 (9.7%) included 3. While
the frequency continued to fall with increasing numbers, the distribution had a long tail, with
a maximum of 29. (See Fig. 1).
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There were a total of 17,232 transitions following a therapist elicitation. (The number of
transitions is slightly less than the number of episodes because some elicitations, such as
those that began a component of the manualized intervention, did not have a baseline.) Of
these elicited episodes with a baseline, 8933 (51.8%) were classified as CT based on the last
MISC-coded client utterance; 3325 (19.3%) were classified as ST, and 4974 (28.9%) as FN.
In an unadjusted cross tabulation, client ST episodes were followed by ST episodes 42.2%
of the time, by CT 34.5%, and by FN 23.3%. Prior client CT was sustained overall 66.9% of
the time, followed by FN 21.5%, and by ST in 11.6% of episodes.
To allow comparison with some prior studies, we also produced simple three-way crosstabulations of client's prior state of CT or ST, the intervening therapist elicitation (open
question, closed question, complex reflections, paraphrasing reflections, summarizing
reflections and advise with permission) and the client's succeeding state of CT or ST (i.e.,
the conventional lag one approach). We compared these results to those obtained using the
episode concept and the final utterance. Results were qualitatively similar, but the lag one
concept generally resulted in a slightly higher probability of maintaining the client’s prior
state. (See Supplemental tables 3 and 4.)
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3.2.
Main effects and full models in multivariable analyses
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The main effects GEE logistic regression model where CT was the outcome showed that
prior CT was indeed the most powerful predictor of subsequent CT (Adjusted Odds Ratio
3.46, 95% confidence interval 3.13–3.86). In addition, open questions, complex reflections,
paraphrasing reflection and summarizing reflections were all significantly associated with
greater odds of subsequent CT than the reference category of closed questions. Advice with
permission was not significantly associated with the odds of CT. In the model where ST was
the outcome, prior CT had a strong inverse relationship with subsequent ST (Adjusted Odds
Ratio 0.21, 95% confidence interval 0.19–0.024). Open questions, paraphrasing reflections,
and summarizing reflections were significantly associated with greater odds of ST, and
advice with permission was significantly associated with less odds of ST. Complex
reflections were not significantly associated with subsequent ST. (See Supplementary Tables
SI and S2 for complete results of the main effects and full model analyses).
Table 3 shows the relationship between elicitations and CT given prior CT and ST,
respectively; while Table 4 shows the relationship between elicitations and ST given prior
CT and ST, respectively. In Table 3, for example, the first column of results shows the total
number of each type of elicitation following Participant CT, and the second column shows
the number and percent of these which were followed by CT. The Adjusted Odds Ratio for
CT compared to the reference category of closed questions, 95% confidence interval, and p-
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value are shown for all elicitations. In these restricted models, Paraphrasing Reflections and
Advice with Permission were not associated with ST transitioning to CT, but Complex
Reflections (AOR = 2.69, p < .0001) and Open Questions (AOR = 1.77, p < .0001) were
associated with this transition type. Summarizing Reflections were also associated with CT
after ST, although this elicitation type was relatively uncommon (AOR = 2.03, p = .0024).
All elicitation types excluding Advice with Permission were associated with subsequent CT
after prior CT, but Open Questions were the least associated with subsequent CT.
Paraphrasing reflections had the strongest association with subsequent change talk after
prior CT (AOR = 1.99, p < .0001).
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Prior CT was most likely to be followed by ST after Summarizing Reflections (AOR = 1.62,
p < .0071), which may reflect that summarizing reflections would have also included
reflections of prior participant ST. Open questions were also associated with increased
likelihood of ST after CT (AOR = 1.42, p < .0001) compared to closed questions. Again,
therapists were instructed to sometimes intentionally elicit ST in the course of the
intervention. Advice with permission was the least likely therapist behavior to elicit ST after
CT (AOR = 0.26, p ≤0.0001).
Prior ST (see Table 4) was most likely to be maintained following paraphrasing reflections
(AOR = 1.62, P < .0001). Advice with Permission was associated with less subsequent ST
(AOR = 0.25, p = .0012). Other reflections were not associated with maintaining ST. Note
that Open Questions are associated with both more CT after ST, and more ST after CT. The
latter is because they are associated with less FN, not less CT.
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All elicitations other than Advice with Permission were associated with the transition from
FN to CT, with Closed Questions as the reference category (Table 5), but only Open
Questions and Summarizing Reflections were associated with the transition from FN to ST.
4.
Discussion
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This study extends the method of sequential analysis of MI technical behaviors in several
notable ways. Here, we explored the relationship between specific counselor elicitation
techniques and client responses of CT, ST, or FN, while accounting for the client's previous
state of motivational expression. We also offer a more comprehensive view of the
therapeutic discourse, by incorporating multiple client statements following a therapist
elicitation rather than a single or two-lag transition. To do so, we classify the meaning of a
given series of motivational statements by how the client's thought is completed. Finally, we
consider how client motivation can be influenced via an examination of which therapist
behaviors can elicit, for example, a statement in favor of change given a preceding statement
against behavior change.
Although one must be cautious about causal inference from an observational study such as
this, the advantages of sequential analyses have been described as follows: “These transition
probabilities, because they preserve the temporal relationship between the process variables,
provide stronger support for a causal hypothesis than would be found in a correlational
design.” (Moyers et al., 2009; p. 1115). In the present study, results suggest that specific MI
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techniques function differently in their association with subsequent client statements about
change. Specifically, open questions and complex reflections are most likely to be associated
with a transition from ST to CT. Open questions are also associated with more ST after CT,
which is consistent with correlational relationships reported in recent meta-analyses (Magill
et al., 2014; Magill et al., 2018; Pace et al., 2017; Romano et al., 2017). Open questions can
have no valence (“Tell me about your drinking”) or can explicitly solicit CT or ST (“Tell me
some of the things you like about drinking” vs “What are some of the not so good things
about drinking?”). The MI therapist will differentially use these techniques depending on
whether the goal is early rapport and engagement or a later focus on motivation for change
(Miller & Rollnick, 2012). In fact, the role of the therapist in eliciting, maintaining, or
changing the nature of client motivational statements has become of such keen interest to MI
process research that the MISC 2.5 now encodes questions and reflections with a subsequent
valence (e.g., complex reflection − CT + or CT ‒) (Houck et al., 2010).
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The present study provides findings complementary to previous work using the Sequential
Code for Process Exchanges (Martin et al., 2005), where valenced elicitations were
originally encoded in MI process research. Here, open questions showed similar odds for
eliciting CT given ST, and ST given CT. In contrast, complex reflections appeared to
preferentially elicit client CT regardless of the prior state, as we also found in the present
study. When the prior state was neutral, complex reflections increased the odds for
subsequent CT only, while open questions increased the odds of both CT and ST. From these
patterns of temporal associations, we suggest that MI therapists effectively use open-ended
questioning for both exploration and motivational enhancement, but complex reflections
appear to function primarily for motivational enhancement.
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Our findings suggest that paraphrasing and simple reflections operate to maintain the status
quo. In other words, if momentum in the direction for or against change is the therapist's
goal, these interventions may be optimal. This pattern of associations has been found in
other sequential analyses, including with other heavy drinking clients recruited in the ED
(Houck et al., 2010) and with heavy drinking, mandated, college students (Apodaca et al.,
2016). Additionally, the use of simple reflections and paraphrasing may be critical to
understanding and clarifying topics being presented by participants. Given the brief nature
of these interventions, there is little room for miscommunication and these specific
techniques can be used to “check in” and ensure therapists and participants are
communicating effectively.
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Taken in sum, since the strongest predictor of CT or ST is the previous client state, therapists
will want to utilize appropriate techniques either to maintain or change the client's state.
Simple and paraphrasing reflections of ST will tend to elicit more ST. (Although we did not
explicitly code the valence of these reflections, they almost always have the valence of the
preceding client utterance.) Although these reflections are considered MI consistent, if the
therapist wishes to move the client from ST to CT, they may be counterproductive. In this
situation, open questions are an effective way to achieve the goal of shifting ST to CT.
Complex reflections may be particularly effective in shifting ST to CT but they are not
always available if the client has not provided the ingredients for them. On the other hand, if
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the therapist's goal is to maintain CT, then simple and paraphrasing reflections may be
relatively more effective.
Our results suggest that it may be useful to distinguish among types of reflections in
therapist training and evaluation of the technical component of MI. Evaluations of MI
fidelity and process may also benefit from a more specific typology than the broad classes of
MICO or MIIN behaviors, and these specific indicators are available in several MI coding
measures (Houck et al., 2010). Furthermore, while the proposed sub-types of complex
reflections were too infrequent to derive probability estimates in relation to CT, ST, or FN,
anecdotal, transcript data suggests they may be useful when employed skillfully by the
therapist and worthy of future consideration in training and research. See, for example, the
following Reflection of Feeling:
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P (Referring to the feedback indicating heavy drinking): Because they're lying. I
don't really care how they're making me look. That's not my problem.
I: I feel like these numbers got you a little upset. I'm feeling a shift a little.
P: Maybe a little bit. I drink more than 95%, I think that's funny, but at the same
time wow, maybe I should cut down a little bit.
Or this example, coded as Agree with a Twist:
P: And the legal limit is what?
I: 0.08 for driving.
P: I don't drive, so I don't have to worry about that.
I: You're right, you don't have to worry about the driving part.
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P: Smart aleck! I have to worry about the drinking part.
4.1.
Limitations and conclusions
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The study has several limitations. It is based on a single intervention, with non-treatment
seeking participants who were heterogeneous in baseline drinking and sex risk behaviors.
Additionally, there were a limited number of therapists across the duration of the study,
limiting generalizations. The sample is not very ethnically diverse and results should be
generalized with caution. We did not code the valence of complex reflections or open
questions, which would have provided more information about the content of these
utterances. Prior research has suggested that the valence of questions and reflections is
strongly related to subsequent client speech. Furthermore, the validity of our findings
depends on our models being correctly specified and that considerable selection bias was not
introduced when controlling for prior state. As this study is exploratory, rather than
hypothesis-driven, replication is required to draw more confident conclusions.
Nevertheless these results have strong face validity and can readily be tested both by
subsequent observational studies and possibly through experimentation. The more complex
operationalization of CT and ST to account for multiple client utterances following an
elicitation also has face validity and may result in more specific and valid evaluation of the
technical hypothesis of MI. It suggests that simply counting the frequency of MICO and
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MIIN behaviors, and the frequency of CT and ST over the course of a session is an
inadequate representation of the technical component of MI, and that conflating complex,
simple and paraphrasing reflections is misleading. It may be profitable to train therapists in
the specific uses of these techniques over the course of an MI session.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
Funding sources
This work was supported by grants U24 AA022003, K05 AA019681, PO1 AA019072, and R01 AA09892 from the
National Institute on Alcohol Abuse and Alcoholism.
Author Manuscript
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Fig. 1.
Number of elicited episodes by episode length. (The right tail is not visible. Maximum
MISC-coded utterance count in an episode is 29.)
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Table 1
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Elicitation concepts.
Label
Definition
Example
Closed Question (Reference
Category)
Questions that require a brief-specific answersuch as yes or no-a choice of limited optionsor simply to specify a number-a color-date-or
time-etc.
Have you thought about completely stopping?
Open Question
A broad question without limited response
categories-i.e. cannot be answered by “yes/no”
or a limited list of choices.
What are some of the good things about alcohol?
Paraphrasing Reflection
The therapist reflects what the client says but
infers additional meaning to test a hypothesis
about the speaker's inner state and encourage
further elaboration
P: Drinking makes it so much easier for me to talk to new
people.
I: You're more social and less nervous around new people
when you drink.
Complex Reflections
(Combined into one category for this analysis)
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Double-sided Reflection
A type of paraphrasing which reflects both
sides of ambivalence asserted by client.
On the one hand drinking with your friends seems to make
it easier to talk to new people – and on the other hand after
a night of drinking you wake up tired and hung over-which
is something you don't like feeling.
Metaphorical Reflection
Speaker replaces a word or phrase in a client’s
assertion with a figure of speech or image
suggesting an analogy
P: I really want to go out and be with my friends but all
they ever do is drink-and I don't want to be around that.
I: You're really stuck between a rock and a hard place.
Reflection of Feeling
Therapist emphasizes emotional content of
client's assertion-perhaps inferring unstated
emotion from body language-tone of voice-or
deduction.
P: I'm constantly being woken up by drunk students.
I: You're angry with the students who disturb your sleep.
Reframing
Acknowledge validity of client's assertion but
offer an encouraging reinterpretation.
P: I have tried so many times and failed.
I: You're very persistent-the change must be important to
you.
Agree with Twist
Similar to reframing but with a more
substantive reinterpretation. Begins with
agreement-changes direction to encourage
goal attainment.
P: I have started walking to class-but I can't seem to get
myself to the gym to work out.
I: You recognize exercise is important-you are putting a lot
of effort to being more active.
Amplified Reflection
Therapist exaggerates or restates client
assertion in a less credible way-to prompt reevaluation.
P: My girlfriend nags me go to the gym and work out.
I: it seems to you that she has no reason for concern.
Summarizing Reflection
(Often serves to end a
segment and
move on; not necessarily
functioning as
an elicitation)
Therapist pulls together highlights of complex
story told by
interlocutor-perhaps over several preceding
turns-in a succinct
restatement.
I: So it sounds like for you-you like sex to be spontaneous.
You
enjoy sex-and there's certain expectations you have on how
it
should go. But when you don't use a condom-it causes you
a lot of worry-anxiety. But on the other hand-there are times
when you don't use a condom-just because you're
spontaneous-or you feel like you know the person.
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Table 2
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Transition frequencies and probabilities for client speech based on intervening counselor facilitative utterances
and simple reflections.
Participant prior speech/
counselor speech
Participant response
Total
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ST: n (p)
CT n (p)
FN n (p)
N
Prior ST/Simple Reflection
157 (.534)
77 (.262)
60 (.204)
294
Prior CT/Simple Reflection
83 (.109)
541
(.718)
137 (.180)
761
Prior FN/Simple Reflection
67 (.154
115
(.264)
254 (.583)
436
Prior ST/Facilitative Utterance
651 (.441)
404
(.274)
420 (.285)
1475
Prior CT/Facilitative Utterance
399 (.138)
1816
(.628)
677 (.234)
2892
Prior FN/Facilitative Utterance
274 (.175)
502
(.320)
793 (.505)
1569
ST = Sustain Talk; CT = Change Talk; FN = Follow Neutral.
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3601
256
358
2090
Paraphrase
Summarize
Advice with
Permission
Closed Question
1237 (59.2)
200 (55.9)
186 (72.6)
2637 (73.2)
206 (72.3)
1480 (64.4)
REF
0.83
1.92
1.99
1.82
1.26
REF
0.65–1.04
1.46–2.51
1.73–2.29
1.42–2.34
1.09–1.46
REF
0.11
< 0.01
< 0.01
< 0.01
< 0.01
p
728
48
96
1525
132
856
212 (29.1)
19 (39.6)
41 (42.7)
462 (30.3)
69 (52.3)
364 (42.5)
N of CT following
elicitation (%)
REF
1.38
2.03
1.08
2.69
1.77
AOR
REF
0.71–2.66
1.30–3.22
0.85–1.36
1.80–4.02
1.38–2.25
95% CI
REF
0.35
< 0.01
0.52
< 0.01
< 0.01
p
Note: Models statistically adjusted for age, race, ethnicity, gender, education, study site, and therapist. CT = Change Talk. AOR = Adjusted Odds Ratio. Ref = Reference Category.
285
2299
Complex Reflection
Open Question
95% CI
N of elicitations
following ST
AOR
N of elicitations
following CT
N of CT following
elicitation (%)
Restricted to prior sustain talk
Restricted to prior change talk
GEE models to interpret effect modification when change talk is the outcome.
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Table 3
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3601
256
358
2090
Paraphrase
Summarize
Advice with
Permission
Closed Question
236 (11.3)
10 (2.8)
44 (17.2)
356 (9.9)
37 (13.0)
347 (15.1)
REF
0.26
1.62
0.87
1.21
1.42
REF
0.15–0.45
1.14–2.29
0.71–1.07
0.88–1.65
1.20–1.68
REF
< 0.01
0.01
0.19
0.25
< 0.01
p
728
48
96
1525
132
856
274 (37.6)
6 (12.5)
34 (35.4)
751 (49.3)
47 (35.6)
318 (37.2)
N of ST following
elicitation (%)
REF
0.25
0.87
1.62
0.91
0.97
AOR
REF
0.10–0.58
0.54–1.42
1.31–1.99
0.61–1.36
0.79–1.19
95% CI
REF
< 0.01
0.58
< 0.01
0.66
0.77
p
Note: Models statistically adjusted for age, race, ethnicity, gender, education, study site, and therapist. ST = Sustain Talk. AOR = Adjusted Odds Ratio. REF = Reference Category.
285
2299
Complex Reflection
Open Question
95% CI
N of elicitations
following ST
AOR
N of elicitations
following CT
N of ST following
elicitations (%)
Restricted to prior sustain talk
Restricted to prior change talk
GEE models to interpret effect modification when sustain talk is the outcome.
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Table 4
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1779
146
139
1368
Paraphrase
Summarize
Advice with
Permission
Closed Question
389 (28.4)
49 (35.3)
69 (47.3)
655 (38.8)
67 (51.2)
591 (42.4)
REF
1.21
2.23
1.55
2.61
1.86
REF
0.84–1.73
1.48–3.39
1.35–1.80
1.82–3.78
1.55–2.23
REF
0.30
< 0.01
< 0.01
< 0.01
< 0.01
1368
193
146
1779
131
1395
206 (15.1)
139 (4.3)
44 (30.1)
266 (15.0)
16 (12.2)
327 (23.4)
N of ST following elicitation
(%)
REF
0.27
2.44
0.99
0.83
1.73
AOR
REF
0.11–0.68
1.51–3.56
0.83–1.20
0.51–1.32
1.43–2.12
95% CI
Note: Models statistically adjusted for age, race, ethnicity, gender, education, study site, and therapist. ST = Sustain Talk. AOR = Adjusted Odds Ratio. REF = Reference category.
131
1395
Complex Reflection
Open Question
p
N of elicitations
following FN
95% CI
N of elicitations
following FN
N of CT following elicitation
(%)
Restricted to prior neutral to predict sustain talk
Restricted to prior neutral to predict change talk
AOR
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GEE models to interpret effect modification restricted to prior neutral.
REF
0.01
< 0.01
0.95
0.43
< 0.01
p
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Table 5
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